Postoperative Horner's Syndrome Research Articles

Robotic Resection of Spinal and Paraspinal Tumors.

Robotic arm surgical systems provide minimally invasive access and are commonly used in multiple surgical fields, with limited application in neurosurgery. Our institutional experience has led us to explore the benefits of a neurosurgeon trained to perform robotic surgery as part of a multidisciplinary team. The objective of this study is to evaluate the feasibility, safety, and outcomes of robotic resection for spinal nerve sheath tumors (NST). Retrospective case series of robotic-assisted intracavitary approaches and resection of NSTs including thoracic, retroperitoneal, and transperitoneal. Surgical outcomes are compared to a historical cohort of open surgical resection of NSTs. Nineteen cases presented, of which 2 were combined posterior spinal followed by robotic tumor resection. One of 19 cases was converted to an open surgery. Gross total resection was achieved in all cases. There were 2 cases of postoperative Horner's syndrome, and 1 case with an intraoperative durotomy that was repaired primarily with no postoperative sequelae. Median estimated blood loss was 50 cc (range: 5-650) and median length of stay was 1 day (range: 0-6), with 9 (47.4%) patients discharged on postoperative day 1 and 3 (15.8%) patients discharged on an outpatient basis. Compared with our previously reported institutional outcomes for open resection of 25 tumors, there was a significant increase in rates of gross total resection (100 vs 60%, P = .002) and decrease in length of stay (median 1 vs 5 days, P < .0001). Robotic resection of complex paraspinal tumors appears safe and effective including for preservation of neurological function and may reduce surgical morbidity. Integration of robotic surgical platforms holds the potential to significantly affect neurological surgery.

Postoperative Horner Syndrome: A Case Report Describing a Rare Complication After Anterior Cervical Discectomy and Fusion

The gold standard for correcting cervical degenerative disc disease (CDDD) is anterior cervical discectomy and fusion (ACDF), which is a safe, effective procedure. Horner syndrome (HS) is an extremely rare complication immediately post-ACDF due to impairment of the sympathetic trunk. Herein, we present the case of a 48-year-old woman with CDDD-related pain and radiculopathy who was counselled and consented for C5–6 and C6–7 ACDF. ACDF was performed with standard anterior left-sided incisions at appropriate levels. Unlike our usual practice, deeper-toothed retractors were employed for better exposure. Two cages were inserted at C5–6 and C6–7. The procedural time was standard (180 minutes), without intraoperative complications. The patient experienced significant symptom relief immediately post-ACDF, but developed sudden onset left-sided HS, with ptosis, miosis, and anhidrosis, approximately 48 hours post-ACDF. At a 2-week postoperative follow-up, she exhibited clinical improvement, and by 12 weeks, her HS had completely resolved. To our knowledge, this case is the first documented instance of delayed-onset HS post-ACDF. It may be associated with the type of retractors used, resulting in neuropraxia or strain on the sympathetic chain ganglia. We recommend adequate exposure while minimizing excessive retraction of the longus colli muscle to reduce irritation to the sympathetic trunk.

Intracapsular Enucleation of Cervical Sympathetic Chain Schwannoma: Improved Strategy of Intraoperative Hemostasis and Better Outcome.

Objective: Intracapsular enucleation (ICE) of cervical sympathetic chain schwannoma (CSCS) is associated with technical difficulties, with diffuse hemorrhage being the main challenge in our previous attempts. This article presents our new strategy for achieving better hemostasis during ICE procedures in CSCS cases. Methods: A retrospective review of CSCS cases treated at our tertiary medical institution was undertaken between April 2018 and February 2024. Only cases with successful ICE were included. Results: A total of 8 cases were included, with 4 male and 4 female patients and an age range of 23 to 77 (average and median ages were 48.5 and 49.5 years, respectively). The presenting symptom was a neck mass for all the patients, with 4 masses on the left and 4 on the right sides. Enucleation was first undertaken for the first 3 cases (before March 2022), followed by hemostasis; this strategy was quite difficult and time-consuming. For the remaining 5 cases, a new strategy was developed to preemptively manage any potential nourishing vessel between the capsule and tumor parenchyma, which significantly decreased operation time (P = .0155) and facilitated hemorrhage control. First bite syndrome (FBS) was avoided in all cases. Postoperative Horner's syndrome (HS) was avoided in 1 patient (Case 6, new strategy) but occurred in 7 patients, taking 8 days to 1 month to recover with the new strategy (4 patients), significantly shorter (P = .0364) than before (3 patients, 1-3 months). The median duration of follow-up was 20 months. No recurrence was documented. Conclusions: ICE was achieved for CSCS cases, especially with our newly developed strategy, by preemptively and securely managing potential nourishing vessels. Operation time and duration of recovery of postoperative HS could both be shortened. Moreover, FBS could be avoided.

Horner Syndrome After Anterior Cervical Discectomy and Fusion: Case Series and Systematic Review

Horner syndrome is an infrequently seen complication of anterior cervical discectomy and fusion (ACDF). Multicenter studies have reported a very low incidence, less than 0.1%. To identify the incidence in, characteristics of, and postoperative course in patients in whom postoperative Horner syndrome developed after ACDF. We performed a retrospective review of all patients who experienced Horner syndrome after ACDF for cervical degenerative disease at a single tertiary care institution between 2017 and 2018. A systematic review was then performed to identify studies investigating prevalence, diagnosis, and treatment of postoperative Horner syndrome after ACDF. Of 1116 patients at our institution who underwent ACDF, the incidence of Horner syndrome was 0.45%. C4/5 and C5/6 were the 2 most common surgical levels. The complication was noted to occur immediately after surgery, and at least partial improvement was identified in all patients an average 3.5 months after surgery (range, 10 days to 6 months). These findings were consistent with our systematic review of 21 studies that showed an incidence of 0.6% (range, 0.02% to 4.0%), the most common surgical level C5/6 (64%), and 82% of patients experiencing at least partial resolution of symptoms within 1 year (60.7% complete, 21.4% partial resolution). Horner syndrome occurs in 0.6% of patients undergoing ACDF. Careful postoperative examination should reveal this complication, which may be underdiagnosed or underreported in larger multicenter case series. The majority of patients experience complete resolution of symptoms within 6 months to 1 year and can be treated conservatively and expectantly.

Rare Complications of Cervical Spine Surgery: Horner's Syndrome.

Study Design:A multicenter retrospective case series.Objective:Horner’s syndrome is a known complication of anterior cervical spinal surgery, but it is rarely encountered in clinical practice. To better understand the incidence, risks, and neurologic outcomes associated with Horner’s syndrome, a multicenter study was performed to review a large collective experience with this rare complication.Methods:We conducted a retrospective multicenter case series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network. Medical records for 17 625 patients who received subaxial cervical spine surgery from 2005 to 2011 were reviewed to identify occurrence of 21 predefined treatment complications. Descriptive statistics were provided for baseline patient characteristics. Paired t test was used to analyze changes in clinical outcomes at follow-up compared to preoperative status.Results:In total, 8887 patients who underwent anterior cervical spine surgery at the participating institutions were screened. Postoperative Horner’s syndrome was identified in 5 (0.06%) patients. All patients experienced the complication following anterior cervical discectomy and fusion. The sympathetic trunk appeared to be more vulnerable when operating on midcervical levels (C5, C6), and most patients experienced at least a partial recovery without further treatment.Conclusions:This collective experience suggests that Horner’s syndrome is an exceedingly rare complication following anterior cervical spine surgery. Injury to the sympathetic trunk may be limited by maintaining a midline surgical trajectory when possible, and performing careful dissection and retraction of the longus colli muscle when lateral exposure is necessary, especially at caudal cervical levels.

Left parapharyngeal ectopic goitre associated with eutopic thyroid and postoperative Horner's syndrome

IntroductionThe authors report a case of left parapharyngeal ectopic goitre, in which resection was followed by postoperative Horner's syndrome, and describe the difficult management of this entity. Case reportA 25-year-old woman presented with upper oesophageal dysphagia and a well-demarcated left parapharyngeal mass displacing the great vessels laterally and posteriorly. The mass was resected via an exploratory neck incision. Histological examination of the operative specimen revealed hyperplastic thyroid parenchyma. The postoperative work-up revealed a eutopic and euthyroid thyroid gland. The postoperative course was marked by Horner's syndrome that persisted at 1-year follow-up. DiscussionParapharyngeal ectopic thyroid coexisting with a functional thyroid is extremely rare. Parapharyngeal masses are usually derived from the parotid gland and nerves. Surgery of the parapharyngeal space can cause injury to the sympathetic trunk, responsible for Horner's syndrome, as in our patient. ConclusionEctopic thyroid should be considered as a possible diagnosis of a parapharyngeal mass. Although rare, Horner's syndrome is a dreaded complication of surgery of the parapharyngeal space.

Bidirectional Approach of Video-Assisted Neck Surgery (BAVANS): Endoscopic complete central node dissection with craniocaudal view for treatment of thyroid cancer.

Endoscopic thyroidectomy is a well-established surgical technique that is mainly performed for benign thyroid disease. We considered that endoscopic surgery could also be widely indicated for the treatment of thyroid cancer. We herein describe our new bidirectional approach of video-assisted neck surgery (BAVANS) for complete central node dissection in endoscopic thyroid cancer surgery. BAVANS involves two different directional pathways to the cervical lesion. Before lymph node dissection, we perform endoscopic thyroidectomy via a conventional gasless precordial or axillary approach. After thyroidectomy, the surgeon repositions by the head of the patient and inserts three ports in front of the upper neck lesion in the submandibular area to approach the paratracheal lesion from an overhead-to-caudal direction. BAVANS allows for an excellent craniocaudal view and easy access to the peritracheal lymph nodes. Sixteen patients with papillary thyroid cancer underwent BAVANS and progressed satisfactorily after surgery. Of those patients, eight underwent total or near total thyroidectomy, and five patients underwent bilateral central node dissection. The average number of retrieved lymph nodes with unilateral central node dissection was nine, which was higher than that achieved with conventional open surgery. All patients began oral intake within 5 h after surgery. Postoperative Horner syndrome occurred in one patient. No other complications were noted. BAVANS is a very effective surgical procedure that many endoscopic surgeons can perform safely and easily. It has both a cosmetic advantage and excellent curability in endoscopic thyroid cancer surgery.

Postoperative Complications Following TECA-LBO in the Dog and Cat

The medical records for 133 total ear canal ablations combined with lateral bulla osteotomies (TECA-LBOs) performed on 82 dogs (121 ears) and 11 cats (12 ears) between 2004 and 2010 were reviewed to determine if the duration of preoperative clinical signs was associated with the incidence of postoperative facial nerve injury and Horner's syndrome. Other perioperative complications, such as a head tilt, nystagmus, incisional drainage, draining tracts, hearing loss, as well as bacterial culture results, were noted. Postoperative facial nerve paresis occurred in 36 of 133 ears (27.1%), and paralysis occurred in 29 of 133 ears (21.8%), with no significant difference between species. Thus, postoperative facial nerve deficits occurred in 48.9% of ears. The median duration of clinically evident temporary facial nerve deficits was 2 wk for dogs and 4 wk for cats. Dogs had a significantly longer duration of preoperative clinical signs and were less likely than cats to have a mass in the ear canal. Dogs were less likely to have residual (> 1 yr) postoperative facial nerve deficits. The incidence of postoperative Horner's syndrome was significantly higher in cats than dogs. The duration of preoperative clinical signs of ear disease was not associated with postoperative facial nerve deficits.

Cervical sympathetic chain schwannoma

Cervical schwannoma is a benign peripheral nerve tumor specifically developing from Schwann cells. Cervical sympathetic chain schwannoma is rare. Following a case report, the authors describe its specific radiological and histological characteristics. Treatment is surgical. A 56-year-old woman consulted for an isolated left lateral cervical mass of several years' standing, but with recently associated pharyngeal discomfort. Cervical CT revealed a vascularized retrostyloid mass with venous-time enhancement, inducing anterior displacement of the jugulo-carotid axis. The tumor could not be identified on fine-needle aspiration cytology, and surgical resection was performed by cervicotomy. Surgical exploration found a tumor developing from the cervical sympathetic nerve, posterior to the jugular vein and carotid sheath. Histopathologic examination diagnosed schwannoma. Postoperative outcome featured Horner's syndrome. Cervical sympathetic chain schwannoma is a rare benign tumor, to be suspected in the presence of an isolated lateral cervical mass. Preoperative CT is mandatory to guide diagnosis; treatment is surgical, to confirm histologic diagnosis. Postoperative Horner's syndrome often confirms cervical sympathetic chain involvement.

Retropharyngeal Ganglioneuroma Presenting with Neck Stiffness: Report of a Case and Review of Literature

Ganglioneuromas rarely occur in the retropharynx with only three cases reported in the current literature. The most common symptom associated with retropharyngeal ganglioneuromas is dysphagia. We report a retropharyngeal ganglioneuroma with an unusual clinical presentation of neck stiffness and pain. A 42-year-old woman presented with incapacitating neck pain, neck stiffness, right upper extremity weakness, as well as dysphagia. Neurological workup was normal. Imaging revealed a hyperdense, ill-defined, diffuse right retropharyngeal mass suggestive of a possible nerve sheath tumor with no communication with the cervical spine. Surgical removal was uneventful and associated with a postoperative Horner's syndrome. In follow-up, dysphagia and neck symptoms improved. Retropharyngeal ganglioneuromas can occur in a wide age range of patients. Surgical excision via a cervical approach offers definitive therapy but may be associated with an iatrogenic Horner's syndrome for which the patients should be counseled prior to operative intervention. Neck pain is an atypical symptom that needs to be worked up to rule out a communication with the spinal column prior to surgical removal. Patients must be counseled that atypical symptoms may not completely resolve with surgical treatment.

Retropharyngeal Ganglioneuroma Presenting with Neck Stiffness: Report of a Case and Review of the Literature

Ganglioneuromas rarely occur in the retropharynx with only three cases reported in the current literature. The most common symptom associated with retropharyngeal ganglioneuromas is dysphagia. We report a retropharyngeal ganglioneuroma with an unusual clinical presentation of neck stiffness and pain. Case report and review of literature. A 42 year old woman presented with incapacitating neck pain and neck stiffness as well as dysphagia. Neurological work up was normal. Imaging revealed a hyper-dense, ill-defined, diffuse right retropharyngeal mass suggestive of a possible nerve sheath tumor with no communication with the cervical spine. Surgical removal was uneventful and associated with a post-operative Horner's syndrome. In follow-up, dysphagia and neck symptoms improved. Retropharyngeal ganglioneuromas can occur in a wide age range of patients. Surgical excision via a cervical approach offers definitive therapy but maybe associated with an iatrogenic Horner's syndrome for which the patients should be counseled prior to operative intervention. Neck pain is an atypical symptom that needs to be worked up to rule out a communication with the spinal column prior to surgical removal. Patients must be counseled that atypical symptoms may not completely resolve with surgical treatment.

Diagnosis and management of cervical sympathetic chain schwannoma: A review of 9 cases

Conclusions. Cervical sympathetic chain schwannoma (CSCS) sometimes mimics carotid body tumor (CBT). Differential diagnosis between these tumors is sometimes difficult using MRI alone. MRA, color Doppler ultrasonography, and fine needle aspiration (FNA) after imaging may be helpful to rule out CBT. Surgical resection of CSCS is relatively effortless, and Horner's syndrome is an expected but acceptable postoperative complication. Intratumoral hemorrhage and vasodilation may be the main reasons for significant enhancement on MRI. Objectives. CSCSs are rare and known to mimic carotid body tumors. We report 9 cases of CSCS with an emphasis on imaging, surgical management, and pathological findings. Moreover, we describe the differential diagnosis of CSCS and CBT, and speculate the reasons behind significant enhancement on MRI. Patients and methods. Nine cases of CSCS treated at a tertiary referral center between 1996 and 2008 were reviewed. Results. MRI revealed 3 of 9 cases (33%) splayed the carotid bifurcation and displayed marked contrast enhancement with gadolinium. All patients underwent surgical excision of the mass with minimal blood loss. Postoperative Horner's syndrome was encountered in all patients, which required no treatment. Marked gadolinium enhancement tended to be associated with histological findings such as intratumoral hemorrhage and vasodilation.

Cervical Sympathetic Chain Schwannoma

Schwannomas are benign, slow-growing tumors that arise from Schwann cells of the nerve sheath. Those originating from the sympathetic cervical chain are rare. Herein, we present three cases of cervical sympathetic chain schwannoma (CSCS) and describe our experience with the clinical presentation, surgical management, and outcomes of patients with this pathology. All three patients were found to have a pulsatile, non-tender mass located at the level of the angle of the mandible without cervical nerve function deficit. On imaging study, the location of the mass between the prevertebral muscle and carotid artery with outward displacement of the carotid sheath is a typical characteristic of CSCS. Operative excision and sacrifice of a portion of the sympathetic chain remains the treatment of choice. Postoperative Horner's syndrome is predictable and vagus nerve dysfunction or first bite syndrome is also possible.

Iatrogenic Horner's Syndrome

To report two cases of Horner's syndrome. One presented after the ablation of a schwannoma of the cervical sympathetic chain, the second after upper thorascopic sympathectomy for primary palmar hyperhidrosis. A 42-year-old man underwent excision of a left neck mass found during routine physical examination. A 20-year-old girl with axillary and palmar hyperhidrosis was treated with cervical sympathectomy. In the early postoperative days, miosis, ptosis, anhidrosis, and enophthalmos were observed. In the ablation of a schwannoma, postoperative Horner's syndrome is associated with the relationship between nerves and the tumor mass, which makes it impossible to separate them surgically in most cases. In thorascopic sympathectomy, patients should be warned of this complication.

Cervical Sympathetic Chain Schwannoma

Schwannomas are benign, slow-growing tumors that arise from nerves. Those originating from the sympathetic cervical chain are rare. We describe our experience with the clinical presentation, surgical management, and outcomes of patients with this pathology. Retrospective chart review of a case series in a tertiary referral center. Four cases of cervical sympathetic chain schwannomas were reviewed. Patients presented with either an asymptomatic neck mass discovered on routine physical examination (1 patient), an enlarging neck mass (2), or an acute onset of a Horner's syndrome (1). All patients underwent preoperative imaging (magnetic resonance imaging, computed tomography, or both). The location and soft-tissue characteristics of the mass, along with displacement of the carotid sheath vessels, were typical of a cervical sympathetic chain schwannoma. All patients underwent surgical excision of the mass. Postoperative Horner's syndrome was encountered in all patients. First bite syndrome was encountered in two patients. Cervical sympathetic chain schwannomas are rare tumors. Preoperative imaging characteristics facilitate the diagnosis. First bite syndrome can occur and may be debilitating postoperatively. Long-term prognosis is excellent.

Horner's syndrome in association with thyroid and parathyroid disease.

Injury to the cervical sympathetic chain and its consequence, Horner's syndrome, as a result of thyroid pathology or surgical intervention is an uncommon complication. The purpose of the present study was to examine the experience of one endocrine surgical unit with pre and postoperative Horner's syndrome. This is a retrospective case series. The study group comprised all patients undergoing thyroid and parathyroid surgery at Royal North Shore Hospital from January 2000 to October 2003 who were identified as having either pre or postoperative Horner's syndrome. Patient demographics, operation performed, underlying pathology and outcomes were evaluated. There were nine cases of Horner's syndrome recorded from a total of 2208 thyroid and parathyroid operations undertaken: three with preoperative Horner's, an incidence of 0.14%, six with postoperative Horner's, an incidence of 0.27%. Patients ranged in age from 22 to 87 years. Two of the three preoperative cases were related to benign pathology, the remaining case having anaplastic carcinoma. Five of the six postoperative cases were related to thyroid malignancy with lymph node dissection; one case was associated with benign parathyroid pathology. Cervical sympathetic chain injury is a rare complication of surgery for thyroid and parathyroid conditions. The presence of preoperative Horner's does not necessarily indicate an underlying malignancy.

First bite syndrome: a complication of surgery involving the parapharyngeal space.

First bite syndrome (FBS) is the development of pain in the parotid region after the first bite of each meal and can be seen after surgery of the parapharyngeal space. The cause is not clear but has been proposed to involve a loss of sympathetic nerve function to the parotid, causing a denervation supersensitivity of salivary gland myoepithelial cells. The purpose of this study was to review the records of 12 patients with FBS to determine any common features of the operations performed that would support this theory of parotid "sympathectomy" as an etiologic factor of FBS. Retrospective review of 12 patients with FBS managed at two tertiary care centers. Twelve patients were diagnosed with FBS after surgery involving the parapharyngeal space. All patients had most of their parotid gland preserved. Six patients exhibited a postoperative Horner's syndrome, suggesting sympathetic chain interruption. The six patients without Horner's syndrome were found to have undergone external carotid artery ligation inferior to the parotid gland, suggesting an interruption of sympathetic innervation to the parotid gland itself. Preservation of parotid gland tissue and a loss of its sympathetic nerve supply, whether by disruption of the cervical sympathetic chain as evidenced by a Horner's syndrome or more selective denervation by ligation of the external carotid artery with its accompanying sympathetic nerve plexus, were common features of all patients. This series supports the concept of parotid "sympathectomy" as an etiologic factor in FBS.

Video-Assisted Modified Left Sympathectomy for Long-QT Syndrome

A 22-year-old female suffering from idiopathic long-QT syndrome complicated by frequent syncope, torsade-de-pointes-type ventricular tachycardia, and asthma, was successfully treated by video-assisted extensive left second and third thoracic sympathetic ganglionectomy, instead of left stellate and first thoracic ganglio-nectomy, to avoid postoperative Horner's syndrome. The QT interval was significantly shortened from 0.6 to 0.43 seconds four days after the surgery. It remained at 0.43 seconds during a 3-month follow-up with no recurrence of tachycardia or syncope.

Transthoracic endoscopic sympathectomy for hyperhidrosis and Raynaud's phenomenon

Over an 80 month period, 53 transthoracic endoscopic sympathectomies were performed in 34 patients. The indications for surgery were palmar hyperhidrosis in 20 procedures (38%), palmar and axillary hyperhidrosis in eight procedures (15%), Raynaud's phenomenon in 23 procedures (43%), and combined palmar hyperhidrosis and Raynaud's phenomenon in two procedures (4%). Follow-up data, obtained by a self-assessment postal questionnaire, was available for 47 procedures in 30 patients (91%). Fourteen out of 15 procedures (93%) performed for palmar hyperhidrosis, all eight procedures (100%) for palmar and axillary hyperhidrosis and 14 out of 22 procedures (64%) performed for Raynaud's phenomenon produced an immediate improvement in symptoms. These improvements were sustained in 13 procedures (87%) performed for palmar hyperhidrosis, all procedures performed for palmar and axillary hyperhidrosis (100%) but only 10 procedures (45%) performed for Raynaud's phenomenon at a median follow-up of 16, 34 and 44.5 months respectively. There were no deaths nor postoperative Horner's syndrome in these patients. The only minor complications were two small pneumothoraces. Compensatory sweating was observed after 24 procedures (51%). These results confirm that transthoracic endoscopic sympathectomy is a simple, safe and effective procedure. In patients with hyperhidrosis, the results are excellent and prolonged; in patients with Raynaud's phenomenon, immediate improvement can be achieved but the symptoms may return with time.

Thorascopic dorsal sympathectomy for hyperhidrosis: A new approach

Thorascopic dorsal sympathectomy for hyperhidrosis: A new approach